JOURNAL OF THE AMERICAN BOARD OF FAMILY
PRACTITIONERS,
Volume 12, Number 1, Pages 16-20, January-February 1999.

Factors Affecting the Circumcision Decision

Jeffrey D. Tiemstra MD

Background: Studies from more than 10 years ago
have shown that most parents choose circumcision for their
infant sons for non medical reasons. Since then a wealth of
data has accumulated on the relative risks and benefits of
the procedure, although the medical community remains
divided on the appropriateness of the procedure. Whether
the ongoing research effort and medical debate have had an
effect on parental decision making is unknown.Methods: a survey of parents of 55 male infants was
conducted to determine when the parents made their decision
regarding circumcision, whether discussions with providers
affected their decisions, and what the results were for
their decisions.Results: Eighty percent of parents made the
circumcision decision before provider discussions.
Seventeen percent reported changing their mind based on the
provider's discussion, although it did not significantly
affect the circumcision rate. Eighty-three percent of
parents reported their attitude as neutral, including 7 of
8 patients who changed their mind based on the discussion
only; only 1 patient was circumcised based on the
provider's recommendation. Predominant reasons were ease of
hygiene (67 percent), ease of infant circumcision compared
with adult circumcision (63 percent), medical benefit (41
percent), and father circumcised (37 percent). Reasons for
no circumcision included unnecessary (73 percent), painful
(36 percent), and father uncircumcised (18 percent).Conclusions: Most parents have made a decision on
circumcision before physicians discuss it, and physician
discussions appear to have little impact on the decision.
Ease of cleanliness is still the most common reason parents
choose circumcision. (J Am Board Fam Pract
1999;12:16-20)

After decades of debate and study, the appropriateness of
routine male circumcision remains uncertain. Potential
benefits traditionally cited include reduced risks of penile
cancer, sexually transmitted disease, and infant urinary
tract infections.1-13 Some
studies have challenged these potential benefits, however,
and critics of routine circumcision have questioned the
degree of risk involved for a strictly preventive
procedure.14-23 Given these
uncertainties, in 1989 the American Academy of Pediatrics
(AAP) modified its earlier statements opposing routine
circumcision24-26 and
emphasized instead the importance of informing parents of
both sides of the debate: "newborn circumcision has potential
medical benefits and advantages as well as disadvantages and
risks. When circumcision is being considered, the benefits
and risks should be explained to the parents and informed
consent obtained."9

Studies done before 1988 clearly have shown that few
parents were aware of the medical debate regarding
circumcision, and most based their choice on concerns
relating to hygiene and appearance.27,28 From 1983 to 1987 four separate
trials tested formal educational intervenions aimed at
discouraging circumcision.29-32
Only one showed a small reduction in the circumcision rate
(72 versus 94 percent), but none showed any improvements in
parents understanding of the medical issues involved despite
the wide range of education levels. In one study the
educational intervention was not only ineffective but also
increased parental dissatisfaction with care. Only one study
specifically addressed the timing of the decision,33 and found that 36 percent of women
chose circumcision even before becoming pregnant. Since the
AAP's 1989 statement emphasizing the informed consent
process, no one has revisited the issue of how or when
parents decide whether to have their sons circumcised.

The goal of this study was to determine whether the
medical debate has had an impact on parents' decision making.
Rather than looking at the content of the consent process and
decision from the provider's viewpoint, I chose to look at
the discussion and decision from the parents' viewpoint by
asking the following questions: (1) when do parents make the
circumcision decision, (2) when do parents discuss
circumcision with their physician, (3) does the decision have
any impact on their decision, and (4) what are the reasons
for their decision? The timing of the circumcision decision
realtive to the discussion with the physician was of
particular interest. If social concerns were more important,
it would seem likely that the decision would be apparent well
in advance of prenatal and neonatal health care encounters,
as indeed, was the case 14 years ago. Conversely, if medical
concerns were more important, then it would seem more likely
that parents would be more open to physicians discussions and
make the final

Methods
A 13-item questionnaire was distributed at two family
practice clinics during a 6-month period. Parents of all male
infants younger than six months of age coming for well-child
care on select days (determined by staff availability) were
approached by a nurse of physican-researcher (not their own
health care provider) and asked to complete the form. The
completed form was collected when the parents left the
waiting room for their infant's examination. Eight questions
were directed at the decision making process and timing, with
multiple choice or yes-no responses, and 3 questions asked
about religion and location of prenatal care. The last 2
questions offered a list of reasons for deciding for or
against circumcision, and respondents were asked to check all
that applied as well as indicate the most important reason.
Analyses of the timing of the decision versus the timing of
the discussion was performed by the chi-square test (3 X 3
table: before, during, or after the pregnancy). Circumcision
rates for parent

Results
Fifty-five surveys were completed. No parent refused to
participate, but 3 surveys were returned uncompleted.
Forty-two parents (76 percent) were seen at site A and
belonged to an health maintenance organization through an
employer or university; of these 23 (42 percent of total)
received prenatal care from a private obstetrician or mures
midwife, and 19 (35 percent of total) received prenatal care
from a family physician. The remaining 13 participants (24
percent) were seen at site B, a community health center for
patients without insurance or on public assistance; of these
10 had received prenatal care from a nurse midwife, and 3
listed other clinics. Respondents named 21 different
physicians or nurse midwives as their providers, representing
7 different clinics. The most frequently reported provider
had 7 patients, and the next most frequent 4 patients; thus
the sample was not skewed by the practice of any single
provider. Forty-four (80 percent) infants had been
circumcised.

(Scanned Image)

Figure 1. Decision timing versus
discussion timing.

Timing of the Decision
Most parents appear to make the circumcision decision early.
Twenty-four (44 percent) reported making the decision before
getting pregnant, but only 4 (7 percent) had discussed
circumcision with a provider prenatally. Of the 19 (35
percent) who made the decision during pregnancy, 8 reported
doing so in the first trimester. Consequently, most parents
(37, 80 percent) reported making the decision before
discussing circumcision with their provider. Figure 1
graphically illustrates this significant discrepancy between
the timing of the circumcision decision and the discussion
with the physician (P<0.005).

The Provider's Role in the Decision
Regarding the character of the providers discussion, 38 of
46 respondents (83 percent) described a neutral process, with
6 (13 percent) having it recommended and 2 (4 percent) being
advised against it. Not surprisingly, then, when asked
whether the discussion had changed the parent's mind about
circumcision, 38 (83 percent) said no. Of the 8 (17 percent
who said yes, 5 (62 percent) chose circumcision, not a
significant difference, 7 reported a neutral discussion, and
only 1 reported a provider expressing an opinion (in that
case favoring circumcision, and that infant was
circumcised).

Of the 6 infants whose providers recommended circumcision,
all were circumcised, whereas of the 2 infants whose
providers recommended against circumcision, whereas of the 2
infants whose providers recommended against circumcision only
1 was not. Seven of these 8 parents reported making their
decision before the provider's discussion; only one chose
circumcision postpartum after having it recommended.

Reasons for the Decision
Table 1 illustrates the relative ranking of reasons for
choosing circumcision. Patients were allowed to check all
applicable reasons and then asked to choose the most
important, if possible. Consistent with past studies, hygiene
and preventing the procedure at a later age were the most
important factors for parents, with other social concerns
being less important. In contrast to past studies, however,
medical benefits were reported more often as reasons for
circumcision.

Table 1. Reasons Parent (n=44) Chose
Circumcision.

Most
Reason* Number Percent Important†

It's easier to keep the penis clean 11 67 18
Its easier to do it now than when he's older 29 63 8
Medically, its better to be circumcised 19 41 10
The baby's father is circumcised 17 37 1
My physician recommended it 6 13 -
My son should be like the other boys 5 11 2
Its important in my religion 5 11 2
Other
Appearance 2 5 -
Culture 1 2 1
Family pressure 1 2
Father insisted 1 2 -

*Respondents were asked to check as
many as applied.
†Not all respondents marked a most important
reason.Table 2. Reasons Parents (n=11) Refused
Circumcision.

Most
Reason* Number Percent Important†
It's just not necessary 8 73 6
It's painful for the baby 4 36 1
The baby's father is not circumcised 2 18 1
Not sure 2 18 1
Other
Hospital failed to do it after birth 1 9 1
Medically its better not to be circumcised 0 0 -
My physician advised against it 0 0 -
I never thought about it 0 0 -

*Respondents were asked to check as
many as applied.
†Not all respondents marked a most important
reason.

Religious requirement for circumcision was not a
significant factor in this sample: only 2 patients (4
percent) belonged to religious groups who require
circumcision (although 3 Christians checked religion as a
secondary reason). Most parents reported their religioun as
Christian (42, 76 percent); 9 (16 percent) reported no
religious affliation: and 1 each (total 4 percent) reported
Hinduism and Buddhism.

Reasons for avoiding circumcision are ranked in Table 2.
No parents reported thinking the uncircumcised state was
medically better: rather, most believed it was simply
unnecessary. Parents did not report the father's status as
important in the decision very often: however, of 8 infants
with reportedly uncircumcised fathers, only 2 were
circumcised.

Discussion
Although this study is clearly limited by the small and
heterogenous sample, the findings are consistent with those
from studies from 15 years ago, which showed that (1) that
the circumcision decision is most often made before parents
discuss the issue with their care providers, (2) that social
concerns are more important than medical ones, and (3) that
providers' discussions have limited impact on the decision
made. Medical benefits were cited more frequently in this
study than in past studies, although medical issues remain
secondary to hygience and convenience. Given the limitations
of this study, the minor increase in parents citing medical
issues might or might not be important. The study design
could have contributed to this finding as well, because the
mere presence of this item on the survey could have prompted
parents to choose it.

If this change is real, then advocates of circumcision
might argue that parents are correctly interpreting the
medical information given them. It is also possible, however,
than parents are choosing the data that support their earlier
decision, or than physicians' neutral discussions of
circumcision might be subtly biased to support the parents'
earlier decision. Two of the 8 physicians who offered a
recommendation had more than 1 patient in the study, and both
were reported by another patient to provide a neutral
discussion. Thus, neutral discussions of circumcision can be
influenced by parents' previous decisions, whether in the
provider's content or presentation or the parent's
perception.

Parents choosing against circumcision did not display
strong beliefs that being uncircumcised was in any way better
or healthier; they simply saw circumcision as unnecessary. An
uncircumcised father appeared to be a strong predictor of the
choice, although it is unclear how this fact affected the
parents' decision-making process. Because these parents did
not rate the father's status as important, having a similar
appearance is probably not the issue. This finding also
raises the issue of whether parents are being provided with
information about the potential medical benefits of not being
circumcised.

The multiple choice design used in this study could have
introduced another bias in this study by forcing parents to
make a decision. This format assumes that parents had some
level of information, at least about the choices they
indicated, when in fact parents might have had very little
information to guide their decision. Thus while some
conclusions can be made regarding the relative weight of
social versus medical concerns, nothing can be inferred from
this study regarding the depth of understanding of
circumcision issues by the respondents.

In summary, then, this study suggests that parents
continue to have preformed decisions regarding circumcision
based primarily on non-medical concerns, which are unlikely
to be changed by attempting neutral discussion of the
relative risks and benefits. Physicians should be aware that
parents who have already made the circumcision decision might
perceive a neutral discussion of circumcision differently
from parents who are undecided. In the former case a
supportive approach is unlikely to change most parents'
decisions, while in the latter a more complete discussion
would be appropriate. Given that most parents make the
circumcision decision early, physicians who wish to affect
the decision should consider discussing it at preconception
visits or early in prenatal care. Regardless of the extent of
the discussion informing the parents' choice, if circumcision
is chosen, informed consent noting the specific immediate
risks must still be obtained.

References

Wiswell T. Circumcision
Circumspection. N Engl J Med 1997;336:1244-5.

Schoen EJ. The relationship
between circumcision and cancer of the penis. CA Cancer J
Clin 1991;41:306-9.

Swafford TD. Circumcision and
the risk of cancer of the penis. Am J Dis Child
1985;139:112.